Current through Register Vol. 35, No. 18, September 24, 2024
The MCO shall establish and maintain an expedited review
process for a MCO expedited member appeal when the MCO, the member or his or
her authorized representative or authorized provider believes that allowing the
time for a standard member appeal resolution could seriously jeopardize the
member's life, health, or his or her ability to attain, maintain, or regain
maximum function. Once a member or his or her authorized representative or
authorized provider requests a MCO expedited member appeal and the member or
his or her authorized representative or authorized provider requests a
continuation of the member's disputed current benefit, the MCO will grant a
continuation of the disputed current benefit until the MCO expedited member
appeal final decision is rendered by the MCO. However, if the date of the MCO
expedited member appeal final decision letter is prior to the notice of
action's adverse action effective date, the MCO must continue the disputed
current benefit up to the adverse action's effective date. The MCO shall ensure
that health care professionals with appropriate clinical expertise in
addressing the physical health, behavioral health, or long-term services and
supports needs of the member are utilized during the MCO expedited member
appeal process when the MCO notice of action for the disputed benefit is based
on a lack of medical necessity.
A. A
member or his or her authorized representative or authorized provider in
accordance with the member's MCO procedures has the right to request within 60
calendar days after the mailing of the MCO's notice of action a MCO expedited
member appeal orally or in writing. When the mailing date of the notice of
action is disputed or there is a discrepancy between the mailing date and the
postmarked date, the postmarked date will prevail.
(1) If a member, his or her authorized
representative or authorized provider elects to request a continuation of the
member's disputed current benefit, the member or his or her authorized
representative or authorized provider must request a MCO expedited member
appeal and request a continuation of the member's disputed current benefit
within 10 calendar days of the mailing of the MCO's notice of action. When the
mailing date of the notice of action is disputed or there is a discrepancy
between the mailing date and the postmarked date, the postmarked date will
prevail. The continuation of the disputed current benefits is not dependent on
the approval to proceed to the MCO expedited appeal process. See
8.308.15.15
NMAC for a detailed description of the continuation of the disputed benefit
process.
(2) If the member or
authorized representative or authorized provider requests a MCO expedited
member appeal, the following applies.
(a) If
the member or his or her authorized representative designate in writing the
member's provider to act as the member's authorized provider, the authorized
provider may request a MCO expedited member appeal when the authorized provider
believes that the MCO has made an incorrect decision concerning the member's
disputed benefit.
(b) If the MCO
upholds its adverse action, regardless of who requested the MCO expedited
member appeal process, the MCO expedited member appeal process is considered
exhausted and the member or his or her authorized representative may request a
HSD expedited or standard administrative hearing concerning the member's
disputed benefit.
(c) Once the
member or his or her authorized representative request a HSD expedited or
standard administrative hearing, he or she is referred to as the
claimant.
(4) The member
or his or her authorized representative or the authorized provider may have
legal counsel or a spokesperson assist him or her during the MCO expedited
member appeal process.
(5) The
member or his or her authorized representative or the authorized provider does
not have the right to request a MCO expedited or standard member appeal or a
HSD expedited or standard administrative hearing related to a value-added
service offered by the MCO.
(6) The
authorized provider is not eligible to request a HSD expedited or standard
administrative hearing on the disputed benefit, unless the provider has been
designated as the member's authorized representative. See 8.352.2 NMAC for a
detailed description of the HSD expedited and standard administrative hearing
processes.
B. The
request for a MCO expedited member appeal may be made orally or in writing to
the member's MCO within the required time frame. The reasons why a MCO
expedited member appeal is necessary must be detailed in the oral or written
request. A member's provider (regardless if the provider is not the authorized
provider) may assist the member or his or her authorized representative in
stating the reasons and providing supporting documentation that a MCO expedited
member appeal is medically necessary. There can only be one MCO member appeal
request concerning the disputed benefit at one time. If the MCO denies the
request for a MCO expedited member appeal, the member or his or her authorized
representative may then request a HSD expedited or standard administrative
hearing regarding the issue of the denial of a MCO expedited member appeal. See
8.352.2 NMAC for a detailed description of the HSD expedited and standard
administrative hearing processes.
C. The MCO shall designate a specific
employee as its MCO expedited member appeal manager with the authority to:
(1) administer the policies and procedures
for resolution of a MCO expedited member appeal;
(2) review patterns and trends in member
expedited appeals and initiate corrective action; and
(3) ensure there is no punitive or
retaliatory action taken against any member, his or her authorized
representative or authorized provider that files an expedited MCO member
appeal, or a provider that supports the member's appeal.
D. The MCO shall provide reasonable
assistance to the member or his or her authorized representative or the
authorized provider requesting a MCO expedited member appeal in completing
forms and completing procedural steps, including but not limited to:
(1) providing interpreter services;
(2) providing toll-free numbers that have
adequate TTY/TTD and interpreter capability; and
(3) assisting the member, his or her
authorized representative or the authorized provider in understanding the MCO
rationale regarding the disputed benefit which was wholly denied, partially
denied or that was limited in order to ensure that the issue under expedited
appeal is sufficiently defined throughout the MCO expedited member
appeal.
E. The MCO shall
provide in writing to the member, his or her authorized representative, and the
member's provider (regardless if the provider is not the authorized provider)
with the following information once a request is made for a MCO expedited
member appeal:
(1) the date the MCO expedited
member appeal request was received by the MCO, and the MCO's understanding of
what the member or his or her authorized representative or the authorized
provider is appealing concerning the member's disputed benefit;
(2) the expected date of the MCO member
appeal decision:
(a) that is not to exceed 72
hours from the date of the receipt of the request for a MCO expedited member
appeal; and
(b) that alerts the
member or his or her authorized representative or the authorized provider of
the possibility of an appeal extension of up to an additional 14 calendar days
when:
(i) the member or his or her authorized
representative or authorized provider requests the extension; or
(ii) the MCO determines it requires
additional information and provides a written justification to the member or
his or her authorized representative or authorized provider, and also places in
the member's MCO expedited member appeal file how the extension is in the best
interest of the member.
F.
Time frames:
(1) The MCO must act as expeditiously as the
member's condition requires, but no later than 72 hours after receipt of a
request for a MCO expedited member appeal, and provide the member and his or
her authorized representative and the authorized provider its MCO expedited
member appeal final decision. The MCO must also make reasonable efforts to
provide oral notice of the decision.
(2) If the member or his or her authorized
representative or the authorized provider requests an extension of the decision
date, the MCO shall extend the 72-hour time period up to 14 calendar days to
allow the member or his or her authorized representative or the authorized
provider to submit additional documentation to the MCO supporting the need for
the MCO expedited member appeal.
(3) The MCO may itself extend the 72-hour
time period when it determines there is a need to collect and review additional
information prior to rendering its MCO expedited member appeal final decision.
The MCO must provide justification in writing to the member or his or her
authorized representative or the authorized provider and also place in the
member's expedited member appeal file how the extension of time is in the
member's best interest.
(4) A
member or his or her authorized representative may file a MCO member grievance
against the MCO's decision to extend the 72-hour time frame and up to an
additional 14 calendar days.
G.MCO-initiated expedited MCO member appeal:
When the MCO determines that allowing the time for a standard MCO member appeal
process could seriously jeopardize the member's life, health, or his or her
ability to attain, maintain, or regain maximum function, the MCO shall:
(1) automatically file a MCO-initiated
expedited member appeal on behalf of the member and continue the disputed
current benefit without cost to the member if the MCO-initiated expedited
member appeal final decision upholds the MCO adverse action;
(2) make reasonable efforts to provide the
member, his or her authorized representative and the member's provider
(regardless if the provider is not the authorized provider) prompt oral notice
of the automatic appeal, following up as expeditious as possible, but within 72
hours of the MCO expedited member appeal final decision; and
(3) use its best effort to involve the
member, his or her authorized representative and the member's provider
(regardless if the provider is not the authorized provider) in the member's
MCO-initiated expedited member appeal. The member's MCO expedited appeal record
will contain the dates, times, and methods the MCO utilized to contact the
member, his or her authorized representative or the authorized provider, or
another provider of the member. If the MCO-initiated member appeal final
decision upholds the MCO's adverse action, the MCO member appeal process is
exhausted and the member or his or her authorized representative may request a
HSD expedited or standard administrative hearing.
